90-1958 - Laserfiche WebLink

Home Browse Search

,f APPLICATION FOR PERMIT 1 •SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1.601 E'. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Sa Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,lob Address 6 � 4 City Lot Size/Acreage Owner's Name i Address �' _ Phone Contractor " Address— ' -^ icense No.? Phone TYPE Of LL/PUMP: NEW WELL-0.. WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well G) PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well D I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL BOTHER WELL - PITS/SUMPS INTENDED USE TYPE OFWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial ❑ Open Bottom, ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl OamesticlPrivate ❑ Gravei.Rack ❑ Tracy Type of g 6 Specifications I'1 Public C7 Other i. .❑ Delta epth of Grout Seal Type of Grout I Irrigation __.,Approx. Depih i ern Surface Seal installed by 1 Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material.& Depth Depth Filler Material & Depth P do TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTIO INo septic system permitted it public sewer is s available within 200 feet.I Installation will serve: Residence— Commercial_ Other Number of living units: Number.of bedrooms _ � Character of soil to a depth of 3 feet: Water table depot SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal i Distance to nearest: Well Foundation Property Line: LEACHING LINE ❑ No. & Length of lines' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth Size — — Number — -- SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS o I hereby certify that hate prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regutatio s of the San Joaquin County Home owner or Ii ensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pars n in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t call for all requi ed specti Complete drawing on reverse side. �J Signed X Title: _ /_ � ' . _ Date: DEPA USE ONLY I Application Accepted by G ` Date A6 Area Pit or Grout Inspection by Date Final Inspection by Date �6 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 box 2009, Stockton, CA 95201 FEE INFO AMOUNT OUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITQNO. 1 EH + EH1�-2aIAEV.I/M5i rQp 7 L` �� ii•26 [ ! V